Refeeding Risk Calculator

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Key Electrolyte Targets:

What is refeeding syndrome?

Refeeding syndrome is a potentially fatal metabolic complication that occurs when nutrition is reintroduced to severely malnourished patients. It causes shifts in fluids and electrolytes (especially phosphate, potassium, and magnesium) as insulin levels increase, leading to cellular uptake and depletion of serum levels.

Why is hypophosphatemia the hallmark finding?

Phosphate is critical for ATP production and cellular function. When feeding begins, glucose stimulates insulin release, driving phosphate into cells for glycolysis. In malnourished patients with depleted total body stores, this can cause severe hypophosphatemia leading to respiratory failure, cardiac dysfunction, rhabdomyolysis, and seizures.

When does refeeding syndrome typically occur?

Refeeding syndrome most commonly occurs within 72 hours of starting nutrition, but can occur up to one week after feeding initiation. The risk period typically extends for 5-7 days, requiring close monitoring during this critical window.

Why is thiamine supplementation so important?

Thiamine (vitamin B1) is essential for carbohydrate metabolism. Malnourished patients have depleted thiamine stores, and refeeding increases demand. Thiamine deficiency can lead to Wernicke-Korsakoff syndrome, lactic acidosis, and cardiac failure. Always give thiamine BEFORE starting nutrition in at-risk patients.

How slowly should I advance nutrition in high-risk patients?

For high-risk patients, start at 25% of calculated requirements (maximum 5 kcal/kg/day or 500 kcal/day, whichever is lower). Advance very slowly over 7-10 days while monitoring electrolytes at least twice daily. The "start low, go slow" approach is critical for preventing complications.

What about fluid management?

Refeeding causes fluid retention due to insulin-mediated sodium and water retention. Start with fluid restriction (especially sodium) and advance cautiously. Monitor for peripheral edema, pulmonary edema, and cardiac failure. Diuretics may be needed but can worsen electrolyte imbalances.

Which patient populations are highest risk?

Highest risk groups include anorexia nervosa patients, chronic alcoholics, oncology patients post-chemotherapy, post-operative bariatric surgery, prolonged fasting, marasmus, malabsorption syndromes, and elderly patients with chronic diseases. ICU patients with prolonged critical illness are also at significant risk.

How do I treat established refeeding syndrome?

If refeeding syndrome develops: reduce caloric intake by 50%, aggressively replace electrolytes (especially phosphate), increase monitoring frequency, give thiamine and multivitamins, manage fluid overload cautiously, and consider cardiology consultation for arrhythmias. Prevention is far better than treatment.